Residents of Văn Chấn District (Yên Bái) register for medical examinations and treatment using health insurance cards at the District Medical Centre. VNA/VNS Photo Việt Dũng

HÀ NỘI - Vietnam Social Security (VSS) is proposing changes to health insurance policies regarding appraisal work, citing outdated and impractical policies that create numerous challenges for social insurance agencies and healthcare facilities.

The current regulations are that health insurance assessments conducted by social insurance agencies include: verifying the procedures for medical appraisal and treatment under health insurance, evaluating prescribed treatments and the use of drugs, medical supplies and technical services and confirming the costs of medical services covered by health insurance.

However, according to social insurance agencies, years of implementation have revealed that this regulation is no longer practical and causes numerous issues for both the agencies and healthcare facilities.

It is also challenging to implement.

In reality, healthcare facilities, with professionally trained doctors and medical experts, are best suited to assess patients' health conditions and provide appropriate treatment. Therefore, assigning social insurance agencies the responsibility of verifying medical prescriptions and services provided by doctors is not aligned with the expertise of health insurance assessors.

Additionally, many treatment assessments require specialised medical boards, while the staff working on health insurance assessments come from various fields, including medicine, pharmacy and finance. The lack of specialised personnel further complicates the situation.

These issues lead to disagreements between social insurance agencies and healthcare facilities regarding assessment results, delaying the settlement of health insurance claims and affecting the operation of healthcare facilities.

A win for everyone

To address these practical challenges, VSS has proposed revising the definition and scope of health insurance assessments in the draft amendments to the Law on Health Insurance.

The proposal suggests that health insurance assessments focus on verifying, reviewing and comparing health insurance claims submitted by healthcare facilities and insured individuals against the relevant legal provisions to determine which expenses are covered by the health insurance fund. It also calls for timely recommendations and warnings to healthcare facilities regarding unreasonable costs to allow adjustments.

This proposal aligns with the government's responsibilities assigned to social insurance agencies, providing detailed guidance on implementing certain provisions of the Law on Health Insurance.

According to social insurance agencies, the proposed revisions to health insurance assessment definitions and content are necessary and urgent.

They aim to address the limitations and challenges of the current law and clarify responsibilities among all parties involved, ensuring feasibility in implementation. The changes will benefit not only social insurance agencies and healthcare facilities but also state health management agencies and the rights of insured patients.

For insured patients, the proposed revisions will not reduce their benefits or affect their health insurance-covered treatments, as the verification process will occur after treatment is completed. Patients will continue to receive appropriate medical evaluations and treatments.

For social insurance agencies, the duties of health insurance assessors will remain the same, involving the verification and review of claims against legal regulations. This ensures that healthcare costs within the scope of the health insurance fund are properly covered, protecting the rights of insured patients.

In recent years, the number of health insurance claims has increased significantly, but the number of health insurance assessors has remained the same due to VSS's strict adherence to downsizing policies set by the government.

For healthcare facilities, the revised definition of health insurance assessments will address inconsistencies between medical expertise at healthcare facilities and social insurance agencies - reducing issues related to policy and legal compliance. This will expedite the settlement of health insurance claims and ensure that healthcare professionals can fulfil their duties according to the Law on Medical Appraisal and Treatment.

State health management agencies will not have to undertake additional tasks, as the oversight of treatment prescriptions, drugs, and service quality will remain under their jurisdiction, as outlined in the Law on Medical Appraisal and Treatment. The revised law will clearly define responsibilities among all parties.

In addition to proposing changes to health insurance assessment definitions, VSS has also suggested various measures to protect the rights of insured individuals. These have been largely incorporated into the draft amendments to the Law on Health Insurance. Proposed changes include allowing individuals with serious or life-threatening illnesses to receive treatment at out-of-network facilities without needing a referral and expanding health insurance coverage for eye conditions such as strabismus and refractive errors for individuals under 18 years old (currently limited to those under six years old).

The draft amendments to the Law on Health Insurance are currently undergoing consultation with ministries, sectors and experts, with plans to be submitted to the National Assembly in October 2024. VNS